obstetric emergencies lydia burland. learning objectives to recognise typical presentations of...

Obstetric Emergencies

Lydia Burland

Learning Objectives

To recognise typical presentations of common obstetric emergencies

Be able to identify ‘at risk’ groups

Know about the initial assessment and management

Answer questions on a range of obstetric topics

Case 1

A 32 year old G1P0 calls her midwife for a check up because she has a severe headache

She is 34+3/40 and has had no problems up to now

She is usually fit and well, with no significant medical history

Case 1

On examination she looks well, and is moving comfortably around the house

GCS 15/15, orientated in time and place

Abdominal examination is unremarkable

What further investigations would you like?

Case 1

Obs: HR 104, BP 153/98, Temp 36.5

Urine: Glucose 1+, protein 2+

What condition are you worried about?

Where should she be referred?

Pre-eclampsia & Eclampsia

Pre-eclampsia; Pregnancy-induced hypertension >20/40 Associated proteinuria (>0.3g in 24o or 1+ on dip) +/- oedema

Severe pre-eclampsia; Systolic >160mmHg or diastolic >100mmHg +/- symptoms or abnormal bloods

Eclampsia; Convulsions on a background of pre-eclampsia


Symptoms of severe pre-eclampsia; Severe frontal headache Oedematous face/hands/feet Liver tenderness, epigastric pain + vomiting Visual disturbance (blurred/flashing lights) Falling platelets and rising ALT Clonus Papilloedema Fetal distress, reduced fetal movements + IUGR


Pathophysiology; Insufficient uteroplacental perfusion Maternal inflammatory response + vascular

endothelial dysfunction

What are the risk factors for pre-eclampsia?


Risk factors; 1st pregnancy/1st pregnancy with new partner Previous pre-eclampsia >10 years since last child Aged >40 years BMI >35 FH of pre-eclampsia PMH of HTN/DM/renal disease


Investigations; BP profile (3x separate readings) Urinalysis, MSU and protein:creatinine ratio FBC, U+E, LFTs + serum urate Fetal assessment (CTG, growth scan + dopplers)

If stable and asymptomatic with normal bloods can be managed and monitored at home

Admit if signs of severe pre-eclampsia


Initial Management; BP 140/90 to 149/99

Check bloods and monitor BP

BP150/100 to 159/109 Start oral labetalol, check bloods and monitor BP

BP >160/110 Start oral labetalol, check bloods and admit


If severe pre-eclampsia not controlled on oral labetalol;2nd line: oral nifedipine3rd line: IV labetalol/hydralazine4th line: IV hydralazine

Plus IV magnesium sulphate for seizure prophylaxis prior to delivery + postnatally

What do we need to do for baby at 34+3?


Approximately 44% of seizures occur postnatally

Post-partum care; Ongoing BP and fluid balance monitoring Continue MgSO4 for at least 24hrs post-delivery Continue oral anti-hypertensives on discharge Community midwife + GP to monitor BP

Case 2:

A G3P2 presents with PV bleeding at 36/40

Passing fresh red blood for last hour, needing 3 pad changes

No associated abdominal pain

What are the possible causes?

Case 2:

From her antenatal notes;Late booker, no antenatal care until 22 weeksRhesus negativeUSS showed posterior placenta, clear of os

On examination;Obs stableAbdomen soft and non-tenderSmall amount of fresh red blood in posterior fornixClosed os, no ectropion

What is an appropriate management plan?

Antepartum Haemorrhage Bleeding from the birth canal after 24 weeks gestation

until completion of the 2nd stage

Affects 2-5% of pregnancies

Causes include;‘show’ cervicitis local traumamalignancy p. praevia* v. praevia*abruption*

Perform an ABCDE assessment and resuscitate appropriately

Admit for investigation and observation

Placenta Praevia

Insertion of placenta in lower uterine segment

Risk factors include previous C-section or placenta praevia, maternal age and parity

Only 3% of p. praevia’s seen at 20/40 persist at term due to lower segment development

Re-scan in 3rd trimester to confirm placement

Placenta Praevia

Grade; 1: placenta <2cm clear of os 2:placenta reaches edge of os 3: partially covers os 4: completely covers os

Risks to mum = massive haemorrhage, surgical complications, air embolism and PP sepsis

Risks to foetus = IUGR, malpresentation, anaemia and cord complications

Placenta Praevia Presents with painless PV bleeding

Unprovoked or post-coital

Diagnosed at 20/40 scan

On examination uterus is soft, non-tender

If suspected avoid VE and arrange USS

Admit for observation and give steroids if <36/40

Deliver if unstable or continuous bleeding by LSCS

Placental Abruption

Premature separation of a normally sited placenta

May be revealed with PV bleeding, or concealed

Often no clear cause, but may follow trauma or SROM in polyhydramnios

Risk factors include maternal HTN, previous abruption, maternal age, parity and smoking

Placental Abruption Risks to mum = hypovolaemic shock, AKI, DIC, PPH and

feto-maternal haemorrhage

Risks to baby = IUGR and pre-term delivery, anaemia and coagulopathy

Presents with abdo pain, +/- PV bleeding, uterine tenderness and fetal distress

If severe there may be progressive shock, abdominal distension and SFH

Diagnosis is clinical, USS may show minor abruption in stable patients

Placental Abruption Management depends on;

severity maternal/foetal conditiongestation associated complications

Severe abruption requires immediate delivery, after correction of any coagulopathy

Conservative management involves serial USS and planned IOL/LSCS by 40 weeks

Be aware of increased risk of PPH following abruption

Case 3:

A G4P3 presents at 39+3 with contractions lasting 60 seconds every 5 minutes

There is no history of SROM

She is otherwise well and has no significant medical or obstetric history (3x NVDs)

What is the next step in management?

Case 3:

On examination the cervix is in mid-position, and dilated 2cm

No liquor or blood is seen

Is she in labour?What management is appropriate?

Case 3:

She opts to go home, returning 3 hours later with a good history of SROM

On repeat examination she is at 8cm

She is therefore transferred to labour ward

2 hours later she goes on to have a NVD, passing the placenta 20 minutes later

Case 3:

Following delivery she has a heavy lochia, and looses an estimated 500mls of blood

What is this known as?

Does she have any risk factors?

How should she be managed?

What is the most common cause?

Post-Partum Haemorrhage Primary PPH = blood loss >500mls from the

genital tract in first 24hrs following delivery

Secondary PPH = blood loss between 24hours and 6 weeks post-delivery

Life-threatening haemorrhage occurs in 1/1000 deliveries

90% are due to uterine atony

Other causes include retained placenta, lower genital tract trauma and uterine inversion

Post-Partum Haemorrhage

There are two key aspects to management;1. Immediate resuscitation2. Identification of the cause

Resuscitation includes an ABCDE assessment with;

2x large bore cannulae FBC/clotting/G+SIV fluids Blood transfusion


Uterine atony;Palpate and rub the uterusEmpty the bladderIV syntocinon infusion (40 units in 4 hours)

Lower genital tract injury;Examine lower genital tract in lithotomy positionSuture any visible injuryIf unable to control insert vaginal pack


Retained placenta;Failure to expel all of the placenta by 30 minutesPrevents uterine contraction and bleedingCommence syntocinon infusionTransfer to theatre for manual deliveryRequires stat dose of IV abx

Other methods of stopping bleeding;Suture placental bed Balloon tamponadeB-Lynch suture Uterine artery ligation

Questions

MCQs

1. Which of the following is associated with severe pre-eclampsia?a. BP >150/95 b. Proteinuria >0.4g/24hrsc. Clonus d. Rising platelets

2. A major transfusion pack should be ordered if more than ____ units are required?a. 2 b. 4c. 6 d. 8

MCQs

3. What is the expected length of time to delivery once pushing is commenced in a primigravid woman?a. 30 minutes b. 1 hourc. 2 hours d. 4 hours

4. What percentage of deliveries will have meconium-stained liquor?a. 5% b. 10%c. 20% d. 40%

MCQs

5. Which of the following is not an indication for episiotomy?a. To assist forceps deliveryb. Failure to progress in 1st stagec. If perineal tear appears inevitabled. Previous pelvic floor surgery

6. What is given in active management of 3rd stage?a. IV Ergometrine b. PR Misoprostolc. IM Syntometrine d. Syntocinon infusion

EMQs

a. Grade 1 p. praevia b. Grade 3 p. praeviac. Placenta accreta d. Placenta percretae. Placenta increta f. Placental abruption

1. A woman presents with retained placenta and severe haemorrhage, resulting in hysterectomy. Histology shows deep myometrial invasion by the placenta.

2. A woman is told following her 20 week scan that she has an anterior placenta encroaching on the internal cervical os.

EMQs


3. An MRI is performed to assess the placenta in a morbidly obese patient thought to have placenta praevia at 20 weeks. The placenta appears to invade through the uterine wall, into peritoneum.

4. A woman is told following her 20 week scan that she has a low-lying placenta <1cm from the os.

EMQs

a. Cervical ectropion b. Grade 3 tearc. Grade 2 tear d. Placental abruptione. Placenta praevia f. Cervical malignancy

5. A woman presents at 28 weeks with post-coital bleeding. Obs are stable, and the external cervical os is red and bleeds on contact.

6. A woman is examined post delivery and found to have a tear involving some of the anal sphincter muscle fibres.

EMQs


7. A woman presents at 28 weeks with abdominal pain and PV bleeding. The uterus is tense and the CTG shows fetal bradycardia.

8. A woman presents at 28 weeks with painless PV bleeding. The abdomen is soft and non-tender. She has had no previous trauma or antenatal care. She admits to 2 previous episodes.

Answers

MCQs

1. Which of the following is associated with severe pre-eclampsia?a. BP >150/95 b. Proteinuria >0.4g/24hrsc. Clonus d. Rising platelets

2. A major transfusion pack should be ordered if more than ____ units are required?a. 2 b. 4c. 6 d. 8

MCQs

3. What is the expected length of time to delivery once pushing is commenced in a primigravid woman?a. 30 minutes b. 1 hourc. 2 hours d. 4 hours

4. What percentage of deliveries will have meconium-stained liquor?a. 5% b. 10%c. 20% d. 40%

MCQs

5. Which of the following is not an indication for episiotomy?a. To assist forceps deliveryb. Failure to progress in 1st stagec. If perineal tear appears inevitabled. Previous pelvic floor surgery

6. What is given in active management of 3rd stage?a. IV Ergometrine b. PR Misoprostolc. IM Syntometrine d. Syntocinon infusion

EMQs


1. A woman presents with retained placenta and severe haemorrhage, resulting in hysterectomy. Histology shows deep myometrial invasion by the placenta.

2. A woman is told following her 20 week scan that she has an anterior placenta encroaching on the internal cervical os.

EMQs




EMQs

a. Grade 1 p. praeviab. Grade 3 p. praeviac. Placenta accreta d. Placenta percretae. Placenta increta f. Placental abruption



EMQs

a. Cervical ectropionb. Grade 3 tearc. Grade 2 tear d. Placental abruptione. Placenta praevia f. Cervical malignancy



EMQs




EMQs


7. A woman presents at 28 weeks with abdominal pain and PV bleeding. The uterus is tense and the CTG shows fetal bradycardia.

8. A woman presents at 28 weeks with painless PV bleeding. The abdomen is soft and non-tender. She has had no previous trauma or antenatal care. She admits to 2 previous episodes.

Any questions?

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